Karch Pharmacology Ch. 16 - Anti-inflammatory, Anti-arthritis
The nurse is discussing ethnic differences in response to medication with your nursing students. What group of people would the nurse tell the students may have a decreased sensitivity to pain-relieving effects of anti-inflammatory drugs and should be educated concerning signs and symptoms of gastrointestinal bleeding from use of these drugs? A) African Americans B) White Americans C) Hispanics D) Asians
A African Americans have a documented decreased sensitivity to pain-relieving effects of many anti-inflammatory drugs. They also have an increased risk of developing GI adverse effects to these drugs. In general, White Americans, Hispanics, and Asians are at lower risk for these problems.
A nurse is assessing a patient who has been taking nonsteroidal anti-inflammatory drugs (NSAID). What statement by the patient indicates to the nurse that the patient has a good understanding of the use of this therapy? A) "I drink a glass of wine just about every night." B) "I asked my doctor to check for blood in my stool regularly." C) "I do not like to swallow tablets so I crush them." D) "I drink as little water as possible when I take my medication."
B Taking certain anti-inflammatory drugs can irritate the gastric mucosa and increase the risk of bleeding; therefore, by asking his or her doctor to check his or her stool for bleeding, the nurse knows that the patient is aware of this. Alcohol and crushing the tablets can interfere with anti-inflammatory metabolism. A full glass of water should be taken with this medication to increase absorption.
When nonsteroidal anti-inflammatory drugs (NSAIDs) are combined with loop diuretics, there is a potential for what? A) Decreased antihypertensive effect B) Decreased diuretic effect C) Lithium toxicity D) Anaphylactoid reactions
B Diuretic effect is often decreased when NSAIDs are taken with loop diuretics. There is a potential for decreased antihypertensive effect of beta-blockers if NSAIDs are combined and there have also been reports of lithium toxicity, especially when lithium is combined with ibuprofen.
A nurse is presenting an educational event for a group of new parents. One topic that the nurse addresses is the overuse of acetaminophen, which can cause liver toxicity. What would the nurse tell the parents it is important to do? A) "Do not give acetaminophen (Tylenol) unless you receive a doctor's order." B) "Check the label of over-the-counter (OTC) medications carefully to watch for inclusions of acetaminophen in the ingredients." C) "Monitor their child's temperature carefully and regulate the Tylenol dose based on the fever." D) "Mix OTC children's medications to get the best coverage for their child's symptoms."
B Inadvertent overdose with acetaminophen frequently occurs because of the combining of OTC drugs that contain the same ingredients. Parents should be taught to carefully check the labels of OTC products and follow the dosage guidelines. A prescription is not required for acetaminophen. Dosage guidelines are the best guide to follow to prevent overdose.
What medication used to treat rheumatic arthritis not only has anti-inflammatory effects but is also used in premature infants to close a patent ductus arteriosus? A) Penicillamine B) Indomethacin C) Antimalarials D) Prednisone
B Indomethacin given IV is used in premature infants to close a patent ductus arteriosus and avoid a surgical procedure. Penicillamine, antimalarials, and prednisone are not used for this purpose.
The pediatric patient has a fever and the nurse is preparing to administer an antipyretic. What drug would be the best choice for this patient? A) Balsalazide (Colazal) B) Naproxen (Naprosyn) C) Indomethacin (Indocin) D) Aspirin
B Naproxen is approved for pediatric use and has antipyretic properties. Balsalazide is used to treat ulcerative colitis and would not be appropriate for treating a fever. Indomethacin has anti-inflammatory effects but does not have antipyretic effects. Aspirin would not be appropriate for treating a child with a fever of unknown origin due to risk of Reye's syndrome.
A patient, newly diagnosed with ulcerative colitis, has been admitted to the short-stay unit. What salicylates does the nurse anticipate will be ordered for this patient? A) Balsalazide (Colazal) B) Sodium thiosalicylate (generic) C) Choline magnesium trisalicylate (Tricosal) D) Salsalate (Argesic)
A Balsalazide is delivered intact to the colon, where it delivers a local anti-inflammatory effect that is most effective for patients with ulcerative colitis. Choline salicylate and salsalate are used to treat pain, fever, and inflammation. Sodium thiosalicylate is used mainly for episodes of acute gout, for muscular pain, and to treat rheumatic fever.
The nurse is preparing to administer a nonsteroidal anti-inflammatory drug (NSAID) to an older patient. What NSAID is associated with increased toxicity and should be avoided if possible? A) Naproxen (Aleve) B) Ibuprofen (Motrin) C) Indomethacin (Indocin) D) Etodolac (Lodine)
A Geriatric warnings have been associated with naproxen, ketorolac, and ketoprofen because of reports of increased toxicity when they are used by older patients. These NSAIDs should be avoided in this population if possible. No such warnings exist for ibuprofen, indomethacin, or etodolac.
When caring for a patient diagnosed with rheumatoid arthritis, the patient tells the nurse that he or she has had insufficient response to nonsteroidal anti-inflammatory drugs (NSAIDs) and his or her condition continues to worsen. What drug does the nurse anticipate will be ordered next for this patient? A) Auranofin (Ridaura) B) Ibuprofen (Motrin) C) Acetaminophen (Tylenol) D) Ketorolac (Toradol)
A Gold compounds such as auranofin are prescribed when more usual anti-inflammatory therapies are ineffective and the patient's condition worsens despite weeks or months of standard pharmacological treatment. Ibuprofen and ketorolac are NSAIDs, which have been tried without good results. Acetaminophen is not an anti-inflammatory and would not be appropriate to control this patient's condition.
What drugs used to treat rheumatoid arthritis are contraindicated in a patient who has a history of toxic levels of heavy metals? A) Gold salts B) COX-2 inhibitors C) Propionic acids D) Fenamates
A Gold salts can be extremely toxic and are contraindicated in the presence of any known allergy to gold, severe diabetes mellitus, congestive heart failure, severe debilitation, renal or hepatic impairment, hypertension, blood dyscrasias, recent radiation treatment, history of toxic levels of heavy metals, and pregnancy or lactation. COX-2 inhibitors, propionic acids, and fenamates have no contraindications related to prior toxic levels of heavy metals.
A patient has been diagnosed with severe rheumatoid arthritis and hylan G-F 20 has been ordered. How is this drug given? A) Injected into the joint B) Orally C) IM D) Sub Q
A Hyaluronidase derivatives (e.g., hylan G-F 20, sodium hyaluronate) have elastic and viscous properties. These drugs are injected directly into the joints of patients with severe rheumatoid arthritis of the knee. They seem to cushion and lubricate the joint and relieve the pain associated with degenerative arthritis. They are given weekly for 3 to 5 weeks and are not given by any other route.
The nurse is caring for a patient who reports taking 800 mg of ibuprofen three times a day for relief of menstrual cramps. What lab results will the nurse find most significant in assessing this patient? A) Complete blood count B) White blood cell differential C) Arterial blood gas D) Cholesterol and triglyceride profile
A Ibuprofen, like all nonsteroidal anti-inflammatory drugs, can cause irritation to the GI mucosa and block platelet clumping, both of which can result in bleeding. Blood loss due to dysmenorrhea can exacerbate these risks so it is important to assess the complete blood count to monitor for excessive blood loss. White blood cell differential would be impacted by infection, which is not indicated here. Arterial blood gas, cholesterol, and triglyceride levels would not be impacted by ibuprofen.
The patient has been diagnosed with rheumatoid arthritis. She also reports pain in various muscle groups secondary to a diagnosis of fibromyalgia and dysmenorrhea with painful cramping during menses. What drug would be most effective in treating all three of this patient's problems? A) Naproxen (Naprosyn) B) Acetaminophen (Tylenol) C) Etanercept (Enbrel) D) Sodium hyaluronate (Hyalgan)
A Naproxen is effective in treating muscle pain, arthritis, and dysmenorrhea. Acetaminophen has no anti-inflammatory effects and would not be helpful for treating arthritis or dysmenorrhea other than some pain relief. Etanercept is useful only for treating rheumatoid arthritis; sodium hyaluronate is used to treat rheumatoid arthritis when other traditional treatment has been ineffective and the condition continues to worsen.
The nursing instructor is discussing COX-2 inhibitors with her nursing students. Where would the instructor tell her students that COX-2 inhibitors work? A) At sites of trauma and injury B) Wherever prostaglandins are present C) At the sites of blood clotting D) In the kidney
A The COX-2 inhibitors are thought to act only at sites of trauma and injury to more specifically block the inflammatory reaction. COX-1 is present in all tissues and seems to be involved in many body functions including blood clotting, protecting the stomach lining, and maintaining sodium and water balance in the kidney.
The nurse teaches a patient with rheumatic disease who is being prescribed salicylate therapy to monitor himself or herself for what? A) Tinnitus B) Visual changes C) Stomatitis D) Hirsutism
A Tinnitus is associated with salicylates. The disease-modifying antirheumatic drug (DMARD) category of antimalarials may cause visual changes, GI upset, skin rash, headaches, photosensitivity, and bleaching of hair. Eighth cranial nerve damage and stomatitis are associated with gold therapy. Hirsutism is associated with corticosteroid therapy.
The nurse assesses laboratory results related to blood clotting when the assigned patient takes what drug regularly? (Select all that apply.) A) Salicylates B) Nonsteroidal anti-inflammatory drugs (NSAIDs) C) Gold compounds D) Acetaminophen E) Disease-modifying antirheumatic drugs (DMARDs)
A, B Salicylates and NSAIDs can both inhibit blood clotting resulting in bleeding if not monitored. Gold compounds, acetaminophen, and DMARDs do not have a known impact on blood clotting.
A patient with rheumatoid arthritis is taking gold salts. What drugs should the nurse teach this patient that are contraindicated when taking gold salts? (Select all that apply.) A) Antimalarials B) Cytotoxic drugs C) Salicylates D) Penicillamine E) Anticoagulants
A, B, D These drugs should not be combined with penicillamine, antimalarials, cytotoxic drugs, or immunosuppressive agents other than low-dose corticosteroids because of the potential for severe toxicity. No contraindication exists for therapy involving gold salts and salicylates or anticoagulants.
The clinic nurse is caring for a patient who is taking a COX-2 inhibitor and knows that this patient needs to be assessed for what? (Select all that apply.) A) Bleeding time B) Liver function C) Altered hearing D) Gastrointestinal (GI) effects E) Water retention
A, D, E COX-2 inhibitors have an impact on many body functions and patients receiving this therapy should be assessed for GI effects, changes in bleeding time, and water retention. Patients taking COX-2 inhibitors do not need to be evaluated for liver function or altered hearing because these are not common adverse effects.
A nurse is caring for a patient in the early stage of rheumatoid arthritis. The nurse would expect what medication classification to be used in the treatment of this patient? A) Antimalarial agents B) Nonsteroidal anti-inflammatory drugs (NSAIDs) C) Xanthine oxidase inhibitors D) Uricosuric agents
B NSAIDs are indicated for relief of the signs and symptoms of rheumatoid arthritis and osteoarthritis, for relief of mild to moderate pain, for treatment of primary dysmenorrhea, and for fever reduction. Antimalarial agents are used in the treatment of systemic lupus erythematosus. Xanthine oxidase inhibitors and uricosuric agents are used in the treatment of gout.
A nurse has admitted a 10-year-old child to the short-stay unit. The child has complained of chronic headaches and his or her mother reports that he or she gives him or her acetaminophen (Tylenol) at least twice a day. What will the nurse evaluate? A) Renal function B) Hepatic function C) Respiratory function D) Cardiac function
B The nurse should evaluate the patient's hepatic function. Severe hepatotoxicity can occur from overuse of acetaminophen. Significant interferences do not occur in the kidney, heart, or lung with acetaminophen.
When the nurse learns that the patient with rheumatic arthritis is complaining of stomatitis, the nurse should further assess the patient for the adverse effects of what medication? A) Corticosteroids B) Gold-containing compounds C) Antimalarials D) Salicylate therapy
B Various adverse effects are common with the use of gold salts and are probably related to their deposition in the tissues and effects at that local level: stomatitis, glossitis, gingivitis, pharyngitis, laryngitis, colitis, diarrhea, and other GI inflammation; gold-related bronchitis and interstitial pneumonitis; bone marrow depression; vaginitis and nephrotic syndrome; dermatitis, pruritus, and exfoliative dermatitis; and allergic reactions ranging from flushing, fainting, and dizziness to anaphylactic shock. The disease-modifying antirheumatic drug (DMARD) category of antimalarials may cause visual changes, GI upset, rash, headaches, photosensitivity, and bleaching of hair. Tinnitus is associated with salicylate therapy. Hirsutism is associated with corticosteroid therapy.
Why do COX-2 inhibitors increase the risk for cardiovascular problems? (Select all that apply.) A) Vasoconstriction is blocked. B) Vasodilation is blocked. C) Platelet clumping is blocked. D) Water and sodium balance is altered. E) Gastrointestinal (GI) integrity is altered.
B, C Recent studies suggest that COX-2 inhibitors may block some protective responses in the body, such as vasodilation and inhibited platelet clumping, which is protective if vessel narrowing or blockage occurs. Blocking this effect could lead to cardiovascular problems. Vasoconstriction is not blocked, water and sodium balance is not altered, and GI integrity is not impacted by COX-2 inhibitors but can be impacted by COX-1 inhibitors.
A mother asks the nurse how acetaminophen works. What statement best describes the therapeutic action of acetaminophen? A) Acetaminophen (Tylenol) works by blocking the increase of interleukin-1. B) Acetaminophen reacts with free-floating tumor necrosis (TNF) factor released by active leukocytes. C) Acetaminophen acts directly on the hypothalamus to cause vasodilation and sweating. D) Acetaminophen is taken up by macrophages, thus inhibiting phagocytosis and release of lysosomal enzymes.
C Acetaminophen acts on the hypothalamus to cause vasodilation and sweating to reduce fever. The mechanism of action as an analgesic is not understood. Anakinra (Kineret) blocks the increased interleukin-1, which is responsible for the degradation of cartilage in rheumatoid arthritis. Etanercept (Enbrel) reacts with free-floating TNF released by active leukocytes in autoimmune inflammatory disease to prevent the damage caused by TNF. Gold compounds are taken up by macrophages, which, in turn, inhibits phagocytosis and releases lysosomal enzymes, which causes damage associated with inflammation.
A mother has brought her 6-year-old child to the clinic. The child has a fever of 102.8ºF and is diagnosed with the flu. What medication will the nurse suggest for this child? A) Etanercept (Enbrel) B) Penicillamine (Depen) C) Acetaminophen (Tylenol) D) Aspirin (Bayer)
C Acetaminophen would be the suggested medication. It is prescribed for relief of pain and fever for influenza in children. Aspirin would be contraindicated because it increases the risk for Reye's syndrome. Etanercept and penicillamine are given for severe rheumatoid arthritis therapy.
A mother brings her 3-year-old child to the emergency department telling the nurse the child has eaten a bottle of baby aspirin. The mother cannot tell the nurse how many tablets were in the bottle. What dose of salicylate would be toxic in a child? A) 2 g B) 3 g C) 4 g D) 5 g
C Acute salicylate toxicity may occur at doses of 20 to 25 g in adults or 4 g in children. Therefore, options A, B, and D are incorrect.
The nurse is teaching the patient, who has been newly prescribed etanercept (Enbrel), how to administer the medication. What statement is accurate? A) "Be sure to drink a whole glass of water when swallowing the pill." B) "Do not take this medication for at least 1 hour after taking an antacid." C) "You can use each of the subcutaneous injection sites to avoid tissue damage." D) "Inject this medication deeply into the muscle to promote absorption."
C Etanercept is given by injecting it into the subcutaneous tissues. The injection sites should be rotated to avoid tissue damage. Because it is not taken orally, there is no requirement related to amount of water to be taken or waiting an hour after taking an antacid. Etanercept is not injected into the muscle but rather into the subcutaneous tissue.
The nurse is caring for a 66-pound child with orders for choline magnesium trisalicylate (Tricosal). The orders read 50 mg/kg/d PO in two divided doses. How many milligram will the patient receive per dose? A) 250 mg B) 500 mg C) 750 mg D) 1,000 mg
C First, the nurse must determine the child's weight in kilogram. One kg is equal to 2.2 pounds. Divide 2.2 into 66 to equal 30 kg. Multiply 50 mg times 30 kg to equal 1,500 mg. Divide 1,500 by 2 for the divided doses, which will equal 750 mg per dose.
A nurse is caring for a patient with severe rheumatoid arthritis who takes anti-inflammatory agents on a regular basis. What medication should the nurse question if ordered by the physician to be taken in addition to the anti-inflammatory agent? A) Oral antidiabetic agent B) Calcium channel blocker C) Beta-blocker D) Antibiotic
C Nonsteroidal anti-inflammatory drugs have the potential to decrease antihypertensive effects from beta blockers if these drugs are taken at the same time. Patients who receive these combinations should be monitored closely and appropriate dosage adjustments made if needed. Drug interactions do not usually occur with oral antidiabetic agents, calcium channel blocking medications, or antibiotics.
A patient presents at the emergency department complaining of dizziness, mental confusion, and difficulty hearing. What should the nurse suspect is wrong with the patient? A) Anakinra toxicity B) Ibuprofen toxicity C) Salicylism D) Acetaminophen toxicity
C Salicylism can occur with high dosage of aspirin. Dizziness, ringing in the ears, difficulty hearing, nausea, vomiting, diarrhea, mental confusion, and lassitude can occur. This combination of adverse effects is not associated with anakinra toxicity, ibuprofen toxicity, or acetaminophen toxicity.
Which of these anti-inflammatory drugs have geriatric warnings? (Select all that apply.) A) Sulindac (Clinoril) B) Indomethacin (Indocin) C) Ketorolac (Toradol) D) Naproxen (Naprosyn) E) Ketoprofen (Orudis)
C, D, E Geriatric warnings have been associated with naproxen, ketorolac, and ketoprofen because of reports of increased toxicity when they are used by older patients. These nonsteroidal anti-inflammatory drugs should be avoided if possible. Sulindac and indomethacin are not associated with toxicity in older patients.
A patient arrives at the emergency department brought by his or her friends. The friends tell the nurse that the patient has taken a whole bottle of aspirin. Blood work for salicylate toxicity is run. What does the nurse expect the results to be? A) >5 g B) >10 g C) >15 g D) >20 g
D Acute salicylate toxicity may occur at doses of 20 to 25 g in adults or 4 g in children. Options A, B, and C would not be high enough to indicate salicylate toxicity.
The nurse is caring for a patient who receives anakinra (Kineret) for arthritis. By what route will the nurse administer this medication? A) Into the affected joint directly B) Oral C) Intramuscular D) Subcutaneous
D Anakinra is administered subcutaneously every day and is often used in combination with other antiarthritis drugs. No other route is appropriate.
A salicylate has been prescribed for a 15-year-old patient who has been diagnosed with arthritis. The mother is concerned about giving her child a salicylate. What salicylates could the nurse tell this mother are recommended for use in children? A) Salsalate (Argesic) B) Olsalazine (Dipentum) C) Sodium thiosalicylate (generic) D) Choline magnesium trisalicylate (Tricosal)
D Aspirin and choline magnesium trisalicylate are the only salicylates recommended for use in children. They should not be used when any risk of Reye's syndrome exists. Salsalate (Argesic), olsalazine (Dipentum), and sodium thiosalicylate (generic) have not been approved for pediatric use and do not provide pediatric dosing guidelines as a result.
What is chrysotherapy? A) Treatment with antimalarials B) Treatment with salicylates C) Treatment with disease-modifying antirheumatic drugs (DMARDs) D) Treatment with gold salts
D Chrysotherapy is the clinical name for treatment with gold salts in which gold is taken up by macrophages, which then inhibit phagocytosis. It is reserved for use in patients who are unresponsive to conventional therapy and can be very toxic. Options A, B, and C are incorrect.
Antipyretic drugs (e.g., aspirin, ibuprofen, acetaminophen) often are used to alleviate the discomforts of fever and to protect vulnerable organs, such as the brain, from extreme elevations in body temperature. However, the use of aspirin in children is limited due to the possibility of what disease? A) Munchausen's syndrome B) Guillain-Barré syndrome C) Angelman's syndrome D) Reye's syndrome
D Salicylates like aspirin are contraindicated for the treatment of childhood fevers because of the risk of Reye's syndrome in children and teenagers. Munchausen's syndrome is an unusual condition characterized by habitual pleas for treatment and hospitalization for a symptomatic but imaginary acute illness. Guillain-Barré syndrome is an idiopathic, peripheral polyneuritis that occurs 1 to 3 weeks after a mild episode of fever associated with a viral infection or with immunization. Angelman's syndrome is an autosomal recessive syndrome characterized by jerky puppet-like movements, frequent laughter, mental and motor retardation, a peculiar open-mouthed facial expression, and seizures. Salicylates like aspirin are not contraindicated for patients with Munchausen's syndrome, Guillain-Barré syndrome, or Angelman's syndrome.
